It’s getting to be a challenge to keep track of the myriad ways in which Obamacare is screwing up the medical insurance and health care markets. This is a government initiative, after all, but was there ever a law so rife with unintended consequences, or a law implemented with such stunning incompetence? I’ve posted on the fallout from the so-called Affordable Care Act (ACA) a number of times in the past, but there’s always some new revelation at which to marvel. Here’s one you might not have heard, but it actually contains a bit of good news: some people are refusing Obamacare exchange subsidies, despite the sometimes strange fact that they qualify at all, which of course is the bad news.

“… some people who qualify for subsidies based on their income could afford to pay their own way. ‘There is no question that we are enrolling people through these programs who would otherwise be considered middle-class or even affluent,’ says Ed Haislmaier, a senior research fellow for health policy studies at the right-leaning Heritage Foundation think tank. ‘We are seeing people with enrollment in these programs that have significant assets, but for whatever reason – usually a temporary reason – fall below the income line.’Those reasons could range from early retirement to a midcareer job change. But whatever the case, some of those who are turning down subsidies are aware others are gaming the system, and they think it’s wrong.”

Well, apparently there is still some honor in the world, even in the face of seduction by the welfare state.

Obamacare contained provisions on electronic health records (EHRs) and was expected to leverage a separate federal initiative on EHRs in the 2009 economic stimulus bill. This too is proving disastrous. Beyond the privacy implications of making medical records accessible to the prying eyes of government bureaucrats and potential hackers, the mandate faced by providers to convert to the EHR system necessitates an extremely time-consuming and costly effort. And the penalty for failing to meet deadlines is a cut in Medicare payments to the provider. No one seems to have considered the supply-side incentive this might create:

“It would thus appear that one method for avoiding the fine would be to stop serving Medicare patients altogether. Well, that’s one way to ration care for the elderly.”

“Rather than saving physicians and health care money, the program in effect has created a new industry — the medical scribe. About 100,000 of these glorified typists are expected to be working for doctors by 2020.‘After five years I can’t really do anything I couldn’t do before the program started,’ says Martin O’Hara, a cardiologist who practices in northern Virginia. Computers make everything more legible, O’Hara says, but otherwise the payoff has been slim.At one hospital in the D.C. area, administrators were pulling their hair out over the huge fees charged to transmit data including routine lab and radiology tests. ‘I talk to EHR vendors all day long and many of them have these criminal-like practices of setting whatever price tag they want because they can,’ said a medical informatics officer who spoke on condition he not be named. … The slow progress of health IT has also put a drag on research.”

Finally, in a post on some basics of good (and bad) health care reformappearing in Mises Daily, Matt Battaglioli discusses the unavoidable reliance on arbitrary methods of rationing in centrally-planned health care systems. (I like that cartoon above, but it’s no joke.) That need is created by a mis-pricing of services. Subsidies prevent consumers from seeing the real cost of routine and non-catastrophic medical services as well as the ex ante, actuarial cost of catastrophic services. Then, unfortunately, the resultant excess demand tends to push costs upward without the natural restraint of a well-functioning market price mechanism. Battaglioli also bemoans the obstacles to competition in the medical field due to licensing requirements and their impact on the supply of care.

Obamacare is under threat on several fronts, including Congress, the courts, consumers, providers, and it’s own clumsy architecture. Apparently congressional Republicans will soon reveal their “one plan” (as described by John Boehner) for health care reform to replace Obamacare. We’ll see if they can do much better.

In advanced civilizations the period loosely called Alexandrian is usually associated with flexible morals, perfunctory religion, populist standards and cosmopolitan tastes, feminism, exotic cults, and the rapid turnover of high and low fads---in short, a falling away (which is all that decadence means) from the strictness of traditional rules, embodied in character and inforced from within. -- Jacques Barzun